Skin Deep - Clinical & Cosmetic Dermatology Blog

Skin Deep is a blog for dermatologists and skin care professionals with focus on theoretical, cosmetic and aesthetic dermatology. This blog is associated with ‘Dermatologists Sans Borders’ one of the largest curated groups of skin care professionals on facebook. If you are looking for non-technical information, please visit

Time to respect your patient privacy

In a small town called payyanur in Kerala, INDIA, three doctors were suspended for allegedly sharing a labour room video of triplets being delivered by C-section on social media. The powerful local media rebuked the medical community for their irresponsible behaviour.

Is taking clinical photos on your mobile second nature for you?   Do you share them on Facebook? 

Photo credit: Jay Wennington @
Think again. In this fast growing digital world, it is time to consider the repercussions. This is not a review of the privacy concerns. Please refer to Kunde (below) for a short and sweet review on ethical and medico-legal considerations of digital photography in dermatology. This is about a solution, though little cumbersome and incomplete.

Dermatology is a speciality that depends on visual cues. Photography can even be considered therapeutic in dermatology, since it is an important part of disease monitoring. Social media like facebook is an important and popular platform for crowdsourcing diagnosis. This is especially important for those practicing in resource deprived areas. How can this be achieved without compromising patient privacy?

I have developed a tool for visual diagnostic information encoding. The tool called LesionMapper(TM) captures information such as location, distribution, progression and severity using pre-defined representative lesion images and icons. It also provides the capability to create lesion icons from existing clinical images. Without further ado here is the link to LesionMapper(TM):

Lesion Canvas for LesionMapper(TM)

The instructions tab has details on how to use it. Below I have added basic steps to add a lesion from your photograph. Please note that using LesionMapper(TM) does not guarantee anonymity. It is your responsibility to ensure that you have obtained the necessary consent. If the preset images and icons are insufficient, you can crop the lesion from the clinical image  itself as below.

  1. Go to
  2. Click on Upload Image 1 (Blue Button)
  3. Upload your image. Select only the lesion and follow instructions. (In the new window)
  4. Click on Upload 1 (White button). Image will be added to canvas. If not press the button again.
  5. Drag the image to the area of involvement. You can resize the image if needed.
  6. Click on the Download button (A small button right below the image). You can also save it on the site. You will be provided with an ID that can be used to render the image by clicking on Load.
Please share below to see the reference to medico-legal considerations in dermatology photography.

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Oral tranexamic acid for the treatment of melasma

My Friend Mr +Devdas Pai  asked for a review of this article [1] (Link to full text below) and our experience on oral tranexamic acid for the treatment of Melasma.

English: Melasma on the face
Melasma on the face (Photo credit: Wikipedia)
I don’t have personal experience using oral tranexamic acid, an antifibrinolytic hemostatic agent with alleged activity as a melanin synthesis inhibitor. Do I think whether this study provides a proof for this activity that was suggested way back in 1979? Not really!

We discussed the methodological challenges in cosmetic dermatology research before and I don’t believe that an RCT should be the gold standard in cosmetic dermatology. But unfortunately, if you set out to prove something in cosmetic dermatology, you invariably can if you use subjective assessments without blinding! When your eyes are not blinded, the random number generator does not do justice in allocation either with a substantial difference in epidermal type of melasma in both groups, enough in my opinion for the demonstrated effect size.

Digital photographs are your best weapon to prove your point. The photograph in the article will probably give you hopes of the miraculous melasma eraser. But you can easily see the difference in white balance between the before and after pictures by looking at the shadow below the nose.

Recurrence is the biggest limitation in melasma management. A statistical quirk has been inappropriately exploited to allude to a sustainable solution without real evidence. The study provides ample proof for the authors conviction in the agent, but not for its actual effect on melasma. Go ahead and try it if you are adventurous. I shall stick to my trusted treatment; PhotoShop :)

Please support below to see the full text of the article.

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Allured to Lignin Peroxidase

In this article I have reviewed lignin peroxidase (LIP) as a skin tone enhancing cosmetic. This is not a paid review.

Various types of cosmetic concealer.
Various types of cosmetic concealer. (Photo credit: Wikipedia)
Is it fair enough to say that 1.3 billion people in Indian sub-continent and many more in the far east have found the panacea for FAIR beautiful skin. Though only few of them will be able to afford LIP and the company aptly follows my time machine rules, I must say that I find the theory behind  LIP (distributed under a popular trade mark name) enticing.

The theory sans all the hype is simple: An isoenzyme of LIP (H1 or modified H2 to be exact) can oxidize melanin in the presence of an electron acceptor in acidic pH. So it is not, 'yet another tyrosinase inhibitor' and theoretically aid removal of already formed melanin. European CRO that reported their "Asian" trials  on company inscribed reports was hardly convincing  with their hanging "significant" improvement in 8 days.

The preparation transiently brings the cutaneous pH to acidic levels for LIP to have its effect. Once the pH returns to normal, LIP disintegrates and vanishes ensuring high safety profile. Since hypopigmenting properties of LIP secreting fungi are long known, this melanin zapper could be a reasonably good addition to any pigmentation treatment (if it were cheaper). It must be noted though that the patent application was filed in 2003 and the idea of a fungal derived fairness agent is not exactly theirs.

I have added LIP to the 'elimination' arm of Pigment Map Project. Do you agree with this placement?

I give 3 peels to the concept (The highest I have ever given to a cosmetic, despite 'sold only to aesthetic physician or spa' marketing gimmick ). Do give your rating using the widget below. peel rating
What is peel score?

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English: 2+ patch test reaction
2+ patch test reaction (Photo credit: Wikipedia)
Back in the dark ages, when I was doing my PG in Manipal, we had something that very few dermatology departments had at that time. The IQ Chamber for applying the European Standard Series on your back to find out what you are allergic to, aptly called a patch test. We published the largest Indian collection (then) of footwear dermatitis results.  ***self promotion :)

Much water has flown down the River Netravati, and patch test has become a common part of dermatology practice. Though we made our own Indian Standard Series, the chambers had to come all the way from Sweeden and USA, reminding us of our inadequacies. But a CRO from Mumbai - CLAIMS claims that the plastic, our own Reliance makes, is as good as their Swedish cousin.

Though this seems relatively straight forward hypothesis to test, CLAIMS has done a remarkably good job in the study design, execution and statistical analysis. Kudos to the CLAIMS team for conducting and publishing this study, though I personally feel the article published in IJDVL (1) could have been improved. Besides a disclaimer that Chamber X is going to be (is being) used/marketed by CLAIMS Pvt. Ltd as "Claims Chambers" would have been appropriate.

Please rate this article:


1. Sajun Merchant SZ, Vaidya AD, Salvi A, Joshi RS, Mohile RB. A new occlusive patch test system comparable to IQ and Finn chambers. Indian J Dermatol Venereol Leprol [serial online] 2014 [cited 2014 Aug 19];80:291-5. Available from:

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Ways to say goodbye to animal testing!

How do you test if a cosmetic (or any material for that matter) is potentially allergic? Apply it in high concentration on a mouse model or inoculate it into the conjunctival sac of a rabbit?
Animal,Porkey Pig, Lobund-Wistar
Animal,Porkey Pig, Lobund-Wistar (Photo credit: Wikipedia)

Thanks to the efforts of NGOs such as 'Aashray' (under the able guidance of Dr +Geraldine Jain ) animal testing of cosmetics in this fashion is banned in several countries including India.

In 2009, Dos santos proposed an innovative computational algorithm to predict the sensitization potential from the chemical structure. But we now know that the allergy is not always caused by the allergen per-se. In most cases the allergen binds with a small molecule in the body called hapten. Hence this structure based prediction was never sensitive enough.

Then came the high-throughput peptide binding assay. This technique essentially measured the binding capacity of allergens to haptens. But there is a catch here too. sensitizer bound to a hapten is not enough to cause allergy. An activation of the pre-hapten has to happen prior to this process for effective sensitization.

A rabbit after a Draize Test
A rabbit after a Draize Test (Photo credit: Wikipedia)
To cut a long story short, this article (1) still in press, proposes a new method that could potentially circumvent all these problems. The method has in fact proved many of the long cherished cytokine heroes inconsequential! The article is published in a journal called 'Toxicology in vitro" and could be technically beyond many of the readers of this blog. So I have tried to summarize it in simple terms below:

The authors have developed a new full-thickness skin model. For technically inclined, the new model is RealSkin cultured together with MUTZ-3. The model simulates the pre-hapten activation process. They studied the cytokine response of untreated model, a vehicle, salicylic acid as an irritant, a low potency allergen - isoeugenol and a high potency allergen - PPD. They found that the well know CD associated cytokines such as IL8  were not different in the above groups.

They studied a list of all 27 cytokines using 2 machine learning techniques. (If you really want to know - it is hierarchical clustering  and support vector machines - SVM). SVM identified the best set of cytokines that could efficiently separate the above groups. The list includes IL-12, IL-9, VEGF, IFN-Gamma, IL-4, PDGF, IL-8, IL-7, GM-CSF, IL-6 and IL-7.

Animal tests are CRUEL
Animal tests are CRUEL (Photo credit: Wikipedia)
Few questions still remain. Will the cytokine secretome pattern remain consistent for other allergens as well especially for allergens such as DNCB? Authors acknowledge that further studies with more allergens are required to prove the concept. That's fair enough.  By the way another study has provided insight into DNCB induced allergic contact dermatitis, with wide reaching clinical implications. ( Shall review that separately later.

So what does this mean to us and the poor animals? We could accurately predict what would happen on mouse skin or rabbit conjunctiva by using just a specialized cell culture and an ELISA kit! Please read the article (1) to learn how. I give 4 peels, since the study is still incomplete. It deserved full five, considering the impact on animal welfare. Do give your rating below!


1. Serom Lee, David Xu Dong, Rohit Jindal, Tim Maguire, Bhaskar Mitra, Rene Schloss, Martin Yarmush, Predicting full thickness skin sensitization using a support vector machine, Toxicology in Vitro, Available online 12 July 2014, ISSN 0887-2333, . ( Keywords: Mutz-3; Skin equivalent; Co-culture; In vitro; Skin sensitization; Support vector machine peel rating
What is peel score?

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Cutaneous Manifestations of Ebola Virus Infection

English: Ebola Hemorrhagic Fever fistribution ...
Ebola Hemorrhagic Fever distribution map of outbreaks in Africa (Photo credit: Wikipedia)
Ebola epidemic was never recognized initially in West Africa as the number of deaths was insignificant compared to more mundane causes such as diarrhea and malnutrition. However an American causality in July 2014 made the word take cognizance of the emerging disaster.

Ebolavirus belonging to the Filoviridae family is one of the most virulent human pathogen causing fulminant hemorrhagic fever with a fatality rate of upto 90%! Fruit bats are the likely reservoir, and human infection occurs through contact with bats or infected animal carcasses or by person-to-person contact (through body fluids, medical care, and burial practices)

Cutaneous manifestations are never prominent but may aid diagnosis. The common cutaneous manifestations are a measles like maculo-papular rash predominantly distributed on the upper arms, flexor surface of the forearms and upper legs. The rash usually starts on the 5th – 6th day subsiding with desquamation after 2 weeks. Desquamation is prominent over the palms and soles. Purpuric or petechial rashes and red eye are also common. Jaundice may be seen in very severe cases with multi-organ failure. Immunohistochemical examination of skin biopsy can confirm diagnosis.

An experimental Ebola vaccine called VSV-EBOV was developed in the Canadian city of Winnipeg recently that offers some hope to the victims. The VSV-EBOV vaccine will be offered to West Africa, though it is untested in humans considering the extraordinary circumstances. The Ebola research in Winnipeg was led by Dr Heinz Feldmann.
Please share to see a summary of 50 recent pubmed articles on Ebola Virus Infection.

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When Can Antibiotics Be Avoided?

English: A ruptured MRSA cyst.
A ruptured MRSA cyst. (Photo credit: Wikipedia)
Last year when I spoke to my friend who is working as an infectious disease expert in Canada, he mentioned that India has a very bad reputation as far as antibiotic usage is concerned. We use antibiotics inadequately and inappropriately so that even our sewage drains are colonized by multidrug resistant bacteria. Emergence of multidrug resistance has become a major problem worldwide. Its impact on healthcare costs especially in poor income countries cannot be overstated.

A review of topical treatments for skin infections by Jonathan Cooke in Medscape dermatology summarizes his findings as below:

“Better clinical trials on the effectiveness and cost effectiveness of wound dressings are needed to ensure evidence based guidance is developed for optimizing the treatment of patients. It is surprising that with the paucity of evidence of clinical effectiveness, health care organizations continue to spend considerable resources on poorly evaluated topical wound products.”

This could be a good dermatology postgraduate research topic. We could design studies to find out whether the results that appear to differentiate between antiseptic agents in microbiological testing can be repeated in the clinical environment for the prevention and management of infections in acute and chronic wounds and probably into its economic impact as well. Experts in this field are invited to provide insights on study design at the popular dermatology thesis topics wiki.
None - This image is in the public domain and ...
(Photo credit: Wikipedia)

The FDA has approved Sivextro (tedizolid phosphate) for the treatment of acute bacterial skin and skin structure infections (ABSSSI) caused by certain susceptible bacteria, including Staphylococcus aureus (including methicillin-resistant strains (MRSA) and methicillin-susceptible strains), various Streptococcus species, and Enterococcus faecalis in adults. Sivextro is available for intravenous and oral use and is marketed by Cubist Pharmaceuticals, based in Lexington, Massachusetts.

The University of Nebraska Medical Center (UNMC) in Omaha has released a mobile app aimed at fighting against antimicrobial resistance, puting the university's clinical guidelines, protocols and dosing adjustments for antimicrobial use into a clinician's hands. Like most other healthcare apps the impact on patient outcome remains to be seen.

What is your take on skin infection control and microbial resistance?

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About Me

As a Dermatologist and Informatician my research mainly involves application of bioinformatics techniques and tools in dermatological conditions. However my research interests are varied and I have publications in areas ranging from artificial intelligence, sequence analysis, systems biology, ontology development, microarray analysis, immunology, computational biology and clinical dermatology. I am also interested in eHealth, Health Informatics and Health Policy.


Bell Raj Eapen
Hamilton, ON

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